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Chapter 20 / Laparoscopic Liver Surgery 251
the transection area, making sure not to injure major tributaries of the
hepatic veins. ese will be taken with staplers. When the transection is
nished, the specimen is removed through the hand port and pneumo-
peritoneum is reinstated to secure hemostasis and repair any bile leaks.
No drains are placed.
We have found that the Pringle maneuver is not necessary for any of
these major hepatectomies and that the blood loss is minimal. In fact, our
blood transfusion rate is less than 5%.
Laparoscopic liver resection is a technique that will be used more fre-
quently in the future. Established advantages like decreased blood loss and
shorter hospital stay will make it even more attractive in the era of cost con-
tainment and bundled payments. Other possible advantages like decreased
complication rates with similar operative times will put this technique even
more in the forefront of the liver surgery armamentarium. Robotic liver sur-
gery is still very undeveloped, but it has great promise not only to achieve
similar results to laparoscopy but also to overcome the limitations of the
latter technique.
Suggested Readings
Buell JF, Cherqui D, Geller DA, et al. e International position on laparoscopic liver
surgery. e Louisville statement, 2008. Ann Surg 2009;250:825–830.
Dagher I, Belli G, Fantini C, et al. Laparoscopic hepatectomy for hepatocellular carci-
noma: a European experience. J Am Coll Surg 2010;211:16–23.
FIGURE 20.2 Trocar placement for laparoscopic right hepatectomy.
Section II / Liver252
Kluger MD, Vigano L, Barroso R, et al. e learning curve in laparoscopic major liver
resection. J Hepatobiliary Pancreat Sci 2013;20:131–136.
Koron AJ, Auenberg G, Kung R, et al. Evaluation of 300 minimally invasive liver
resections at a single institution. Less is more. Ann Surg 2007;246:385–394.
Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection.
AnnSurg 2009;250:831–841.
Nguyen KT, Laurent A, Dagher I, et al. Minimally invasive liver resection for metastatic
colorectal cancer. Ann Surg 2009;250:842–848.
SECTION III
Biliary
254
is chapter is an overview of hepatobiliary anatomy. It covers the prevailing,
that is, commonest anatomic patterns and common anomalies, with empha-
sis on surgically important anomalies.
ANATOMY AND NOMENCLATURE OF THE LIVER
e Brisbane 2000 Terminology of Hepatic Anatomy and Resections used
throughout this chapter is the ocial nomenclature adopted by the
International Hepato-Pancreato-Biliary Association.
Ramication of the Hepatic Artery
e primary ( rst-order) division of the proper hepatic artery is into the
right and left hepatic arteries (Fig. 21.1). ese branches supply arterial
inow to the right and left hemilivers or livers (Fig. 21.2). e border or water-
shed of the rst-order division is the midplane of the liver. It intersects the
gallbladder fossa and groove for the inferior vena cava (IVC) (Fig. 21.2). e
right liver usually has a larger volume than the left liver (60:40), although
this is variable.
e second-order branches (Figs. 21.1 and 21.2) of the hepatic artery
supply the four hepatic sections. e right liver has two sections, the right
anterior section and the right posterior section, supplied by the right anterior
sectional hepatic artery and the right posterior sectional hepatic artery,
respectively (Fig. 21.1). e plane between these sections is the right inter-
sectional plane, which does not have surface markings to indicate its posi-
tion (Fig. 21.2). e left liver also has two sections, the left medial section
and the left lateral section, which are supplied by the left medial sectional
hepatic artery and the left lateral sectional hepatic artery (Fig. 21.1). e
plane between these sections is referred to as the left intersectional plane.
It does have surface markings indicating its position—the umbilical ssure
and the line of attachment of the falciform ligament to the anterior surface
of the liver.
e third-order branches of the hepatic artery divide the right
and left hemilivers into segments 2 to 8 (Figs. 21.1 and 21.2). Each of
the segments has its own feeding segmental artery. e left lateral sec-
tion is divided into Sg2 and Sg3. e pattern or ramication of vessels
within the left medial section does not permit subdivision of this sec-
tion into segments, each with its own arterial blood supply. erefore,
the left medial section and Sg4 are synonymous. However, segment 4 is
arbitrarily divided into superior (4a) and inferior (4b) parts. e right
anterior section is divided into two segments, Sg5 and Sg8. e right
posterior section is divided into Sg6 and Sg7. e planes between seg-
ments are referred to as intersegmental planes. e ramications of the
bile ducts are identical to that described for the arteries as are the zones of
the liver drained by their respective ducts.
Liver and Biliary Anatomy
Steven M. Strasberg
21
Chapter 21 / Liver and Biliary Anatomy 255
Segment 1 (caudate lobe) is a distinct portion of the liver, separate
from the right and left hemilivers. It has three parts: the bulbous left part
(spigelian lobe); the paracaval portion, which lies anterior to the vena cava;
and the caudate process (or right part), on the right (Fig. 21.3). e cau-
date lobe is situated posterior to the hilum and the portal veins. e cau-
date receives vascular supply from both right and left hepatic arteries (and
portal veins). Caudate bile ducts drain into both the right and left hepatic
ducts. e caudate lobe is drained by several short caudate veins that enter
the IVC directly. ese veins enter the IVC on either side of the midplane
of the vessel, an anatomical feature that normally allows the creation of a
tunnel behind the liver on the surface of the IVC without encountering the
caudate veins.
Resectional Terminology
Anatomic liver resections are hemihepatectomies (or hepatectomies), sectio-
nectomies, or segmentectomies. e nomenclature for specic resections is
described in Figures 21.4 to 21.8.
Resection of segment 1 is usually called a caudate lobectomy.
FIGURE 21.1 Three orders of ramication of the proper hepatic artery are shown color
coded. First order (red) is division into right (A) and left (B) hepatic arteries. The second
order is division into sectional arteries (green), including the right anterior (c), the right
posterior (d), the left medial (e), and the left lateral (f) sectional arteries. The third-order
division (blue) is into segmental arteries that are numbered and correspond to the Couinaud
segments. The three orders supply the hemilivers or livers, sections, and segments. Note
that the second order and third order for the left medial sectional artery and artery to seg-
ment 4 are identical (banded green and blue). Segment 1, which is separate from the two
hemilivers, is supplied by the arteries that arise from the right and left hepatic arteries (not
shown). Ramication of the bile ducts is identical to that of the arteries. (From Strasberg
SM, Philips C. Use and dissemination of the Brisbane 2000 nomenclature of liver anatomy
and resections. Ann Surg 2013;257(3):377–382.)
Section III / Biliary256
FIGURE 21.2 A. First-order division of the liver into the hemilivers or livers. Midplane of
the liver shown in red. B. Second-order division of the liver into sections. (RPS, right poste-
rior section; RAS, right anterior section; LMS, left medial section; LLL, left lateral section.)
The intersectional planes are shown in green.
Midplane of Liver
Left Hemiliver/Liver
First Order: The Hemilivers or Livers
Line of insection of vessel
s
and bile ducts
Inferior vena cava
Right Hemili
ver/Liver
A
Right
Intersectional
Plane
RPS
RAS
LMS
LLS
Second Order: The
“Sections”
Left
Intersectional
Plane
B
(Continued)
Chapter 21 / Liver and Biliary Anatomy 257
SURGICAL ANATOMY FOR LIVER RESECTIONS
Hepatic Arteries and Liver Resections
In the prevailing anatomic pattern, the celiac artery terminates by divid-
ing into splenic and common hepatic arteries. e common hepatic artery
runs anteriorly and to the right to ramify into gastroduodenal and proper
hepatic arteries. e proper hepatic artery enters the hepatoduodenal liga-
ment and normally runs for 2 to 3 cm along the left side of the common
bile duct (CBD) and terminates by dividing into the right and left hepatic
arteries, the right immediately passing behind the common hepatic duct
(CHD). e four sectional arteries arise from the right and left arteries
1 to 2 cm from the liver. Variations from this pattern, such as replaced (aber-
rant) arteries, are common. “Replaced” means that the artery supplying a
particular volume of the liver is in an unusual location and also that it is the
FIGURE 21.3 Anatomy of caudate lobe. Segment 1-1,
caudate lobe proper; Segment 1-r, caudate process; MHV,
middle hepatic vein; PV, portal vein; IVC, inferior vena cava
7
6
5
1
4
8
2
3
Third Order: The “Segments”
C
FIGURE 21.2 (Continued) C. Third-order division into numbered segments. (From
Strasberg SM, Philips C. Use and dissemination of the Brisbane 2000 nomenclature of liver
anatomy and resections. Ann Surg 2013;257(3):377–382.)
Section III / Biliary258
sole supply to that volume of the liver. is should not be confused with the
term “accessory” artery. Accessory in this sense indicates that the artery is
not the sole blood supply to an area (Fig. 21.8).
Part or all of the liver is supplied by a replaced artery in 25% of patients.
e replaced right hepatic artery arises from the superior mesenteric artery
FIGURE 21.4 Resectional terminology for excision of a hemiliver or liver. (From Strasberg SM,
Philips C. Use and dissemination of the Brisbane 2000 nomenclature of liver anatomy and
resections. Ann Surg 2013;257(3):377–382.)
FIGURE 21.5 Resectional terminology for excision of a section. (From Strasberg SM,
Philips C. Use and dissemination of the Brisbane 2000 nomenclature of liver anatomy and
resections. Ann Surg 2013;257(3):377–382.)
Chapter 21 / Liver and Biliary Anatomy 259
(SMA) and usually runs behind and then along the right posterior border of
the CBD (Fig. 21.8), where it may often be palpated. It may supply a segment
of, a section of, or the entire right hemiliver. e replaced left hepatic artery
arises from the left gastric artery and courses in the lesser omentum to the
liver. Rarely, a replaced artery supplies the entire liver, and then it is called a
replaced common hepatic artery.
Bile Ducts and Liver Resections
e prevailing pattern of bile duct drainage from the right liver is shown in
(Fig. 21.9A). ere are important biliary anomalies on the right side of the
liver. e right posterior sectional duct inserts into the left hepatic duct in
FIGURE 21.7 Terminology for extended resections (three sections). (From Strasberg SM,
Philips C. Use and dissemination of the Brisbane 2000 nomenclature of liver anatomy and
resections. Ann Surg 2013;257(3):377–382.)
FIGURE 21.6 Resectional terminology for excision of a segment. (From Strasberg SM,
Philips C. Use and dissemination of the Brisbane 2000 nomenclature of liver anatomy and
resections. Ann Surg 2013;257(3):377–382.)
Section III / Biliary260
20% of persons (Fig. 21.9B), and the right anterior bile duct does so in 6%
(Fig. 21.9C). A right sectional bile duct inserting into the left hepatic duct
is in danger of injury during left hepatectomy. Another important anomaly
is insertion of a right bile duct into the biliary tree at a lower level than
the prevailing site of conuence (Fig. 21.9D). e latter anomaly places the
aberrant duct at great risk for injury during laparoscopic cholecystectomy.
e prevailing pattern of bile duct drainage from the left liver and
common anomalies is shown in Figure 21.10.
Portal Veins and Liver Resections
On the right side of the liver, the portal vein divisions correspond to those of
the hepatic artery and bile duct, and they supply the same hepatic volumes
(Fig. 21.11). It divides into two sectional and four segmental veins as do the
arteries and bile ducts. e left portal vein consists of a horizontal or trans-
verse portion, which is located under Sg4, and a vertical part or umbilical por-
tion, which is situated in the umbilical ssure (Fig. 21.11). Unlike the right
portal vein, neither portion of the left portal vein actually enters the liver,
but rather, they lie directly on its surface. Often, the umbilical portion is hid-
den by a bridge of tissue passing between left medial and lateral sections.
e junction of the transverse and umbilical portions of the left portal vein
is marked by the attachment of a stout cord—the ligamentum venosum.
is structure, the remnant of the fetal ductus venosus, runs in the groove
between the left lateral section and the caudate lobe and attaches to the left
hepatic vein/IVC junction.
Portal vein
Gallb
ladder
Celiac trunk
Stomach
Pancreas
Cystic ar
tery
Proper
hepatic ar
tery
Right gastr
ic artery
Pylo
rus
Duodenu
m
Gastroduodenal ar
tery
A Normal anatomy
Accessory left hepatic artery
Replaced common hepatic artery off SMA
Splenic artery
B Replaced left hepatic artery
Cystic artery
Hepatic duct
Portal vein
Replaced left
hepatic artery
Proper
hepatic artery
Gastroduodenal
artery
C
D Replaced right hepatic artery
Proper
hepatic ar
tery
Gastroduodenal ar
tery
Left gastric
artery
Accessory
left hepatic
artery
Splenic artery
Portal vein
Splenic artery
Replaced right
hepatic artery
Superior
mesenteric
artery
E
F Anterior location of right hepatic artery
Gastroduodenal
artery
Proper
hepatic ar
tery
Gastroduodenal ar
tery
Splenic artery
Hepatomesenteric
trunk
Replaced
hepatic ar
tery
Lienogastric
trunk
Portal vein
Celiac trunk
Stomach
Pancreas
Right hepatic
artery
Aorta
Aorta
Aorta
FIGURE 21.8 Prevailing pattern (“normal anatomy”) and some common variations of the
hepatic artery. (From Mulholland MW, Lillemoe KD, Doherty GM, et al. Greeneld’s surgery:
scientic principles & practice, 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2010.)